Appendix 2

Clinical Audit Work Request & Registration Form

(Form to be completed when the audit is in addition to the agreed RDaSH Clinical Audit Work Programme)

Audit Title:

Audit Lead(s):

Titles(s):

Tel No: Email Address:

Care Group:

Rotherham Doncaster North Lincs Children’s

Service:

Adult Community Adult Inpatient MH Older People MH Drug and Alcohol

CYP+F CAMHs Medical/Pharmacy Learning Disabilities DCIS

Corporate Services Forensic

Will this be a Trust wide or locality specific audit?

Trustwide Locality Specific Locality to be involved:

If the project is not to be undertaken Trustwide (i.e. throughout all adult inpatients services), please indicate the reasons why:

Type of Work:

Clinical Audit Clinical Effectiveness

Clinical Assurance Category:

Safety Patient Experience Effectiveness

Reason for the Audit:
National Audit / CQC, state No: / CQUIN / NHSLA Risk M. Standards
Identified on Risk Register / Quality Marker / Performance Indicators / NICE Guidance, state No:
Complaint / Incident / Contractual / Commissioner Requirement / Area of Concern / Re-audit
Other, please state:

Main Aims/Objectives for the audit: (what do you want to achieve or assess?):

What criteria and standards are you going to measure, i.e. what is the aspect of care that you are going to examine and what target are you going to set?

Criteria Number / Criteria / Standard (%)
1
2
3
4
5

Continue on separate sheet if necessary

Audit Methodology:
ProspectiveRetrospective Concurrent
Prevalence (held on one specific day)
Data collection Method:
Data collection proformaQuestionnaire Interview
Other please specify:
Data source:
Patient records Computer held information
Patient experience Staff experience
ObservationOther please specify:

Stakeholders:

Have key people been made aware of this audit (ie people who will be providing services covered by this audit)? Yes No

It is essential that anyone who will be providing services covered by this audit are made aware of the audit at the start to ensure where any changes are required at the end that they fully understand why these are necessary.

Please state the expected START date of the audit/project:

Please state the expected COMPLETION date of the audit/project:

Do you require any support from the Clinical Audit Team? Yes No

If yes, please state what support you require from the Clinical Audit Team:

Advise on how to conduct the audit Data input Data analysis

Typing of tables / graphs for presentation of results

Support with completing the audit report

Other please specify:

PRIORITISATION SCORE SHEET

Please complete the following prioritisation scoring sheet to establish the level of priority for the project. Following your submission of the work request form, the Clinical Quality Group will consider the appropriateness of the project in order to identify available resources within the Clinical Audit Team. Projects scoring a medium/high will be considered for support. Projects scoring low will be considered a low priority and therefore, support from the Clinical Audit Team may not be approved.

If you require any assistance in completing the work request form / prioritisation score sheet, please contact the department on 01302 796728.

Audit Title
Score / Maximum allowed
Reason for undertaking this audit project Max = 38
Compliance with national and local clinical priorities / Max = 11
National clinical guidance e.g. NICE, New Horizons / 2
Identified by the Care Quality Commission (CQC) Fundamental Standards for Healthcare / 2
CQUIN / 2
Commissioner Request/Requirement / 2
Quality Marker / Performance Indicator / 2
Local Care Group identified audit / 1
Management of risk / Max = 5
Problem identified through clinical incident reporting/significant event analysis / 1
Problem identified through patient complaint/complaint monitoring / 1
Topic through risk management process e.g. NHSLA / 1
Issue identified through litigation/risk of litigation / 1
Identified though the risk register / 1
Other / Max = 5
Relates to strategic goals/objectives / 2
Patient/carer feedback / 2
Need for re-audit of previous topic / 1
Area of Clinical Practice / Max = 4
One of high volume / 1
One associated with high costs / 1
One of concern (i.e. outcomes/practice could be improved / 1
One where there has been a change in practice requiring evaluation / 1
Evidence based Guidelines / Standards / Max = 9
NICE / 2
CQC Standards / 2
Royal College / 1
Other Professional bodies / 1
Policy / 1
Locally developed clinical guidelines / 1
Locally adopted clinical standards e.g. Essence of Care / 1
Involvement of agencies / disciplines / users / Max = 4
Multi – Organisational e.g. GP’s / 2
Multidisciplinary / 1
Identification / development of audit topic by service user / 1
Project Total (max = 38)

Key: 0- 13 = Low 14-26 = Medium 27-39 =High

Has this audit been discussed and approved by your Care Group YES NO

Has this audit been discussed and approved by your Governance Group?

YES NO

Who has approved this audit?

Care Group Director Date: please print name:

Associate Nurse Director Date: please print name:

Consultant Date: please print name:

Signed: Job title: Date:

Please return this form by post to: Clinical Audit Team

Chestnut View, Tickhill Road Site, Doncaster

Or email: